Today is October 6, 2019, and the contradiction remains in NTSB report RAB 1901 even though it has been directly reported, by me via telephone May 2019, to NTSB.
Why am I not surprised?
After the impact, at 11:18 p.m., the engineer placed the train into emergency braking, announced emergency three times on the radio,
According to the event recorder and the engineer interview, the Amtrak engineer responded immediately and applied emergency braking upon seeing the CSX employees walking near the tracks.
FYI: Event recorders cannot sense impact.
Somebody has an ax to grind.
CSSHEGEWISCHSomebody has an ax to grind.
No resumption of ad hominems, please. There may be a point of actual interest here.
Clearly the NTSB has no particular interest in revising its work product. What's going to be interesting is that lawyers are going to take a particular interest in this issue, and perhaps specifically in errors in the NTSB work product, at which point I somewhat grimly expect to see an increasing flood of changed versions, perhaps with hysterical accompanying letters throwing the perceived culprits under the bus. In certain government prosecutions and proceedings, dotting the 'i's and crossing the 't's in legal material is of almost NS-like preternatural importance, regardless of cost.
Probably more likely is a note from someone at NTSB over the Secretary's signature indicating that what they meant 'all along' was what is indicated (overt and tacit) in their interview results and the logical conclusions that can be drawn from them. And then the beat will go on.
I would agree, though, that this is likely not a 'smoking gun' proving nitwit incompetence at the NTSB. Although I would not be too keen on having to argue the point...
CSSHEGEWISCH Somebody has an ax to grind.
Pointing out an obvious contradiction/error is considered having "an ax to grind"?
OvermodClearly the NTSB has no particular interest in revising its work product.
Wouldn't the NTSB report be considered "evidence"?
As such I believe it needs to be protected "warts and all" through the entire process. You really wouldn't want evidence to be tampered with even when some well meaning samaritan phones in a correction, let alone anyone who might have a vested interest.
Kind of like the thread about the letter to the head of Amtrak. With the target surrounded by an army of well paid experts expected to have a mastery of their field, isn't it rather grandiose for John Q Public to assume that such people eagerly await input from the peanut gallery ?
243129 CSSHEGEWISCH Somebody has an ax to grind. Pointing out an obvious contradiction/error is considered having "an ax to grind"?
Applies to various staff at the NTSB too. Speaking as a cynic, if there is an issue, almost everyone has an ax needing at least some grinding. Or as lawyers say with considerable truth, "It all depends on whose ox is being gored. "
By statute, NTSB reports are not admissible in a court of law.
CSSHEGEWISCHBy statute, NTSB reports are not admissible in a court of law.
Didn't know that...very interesting....thanks
You motivated me to dig deeper, and not surprisingly there is a specific protocol to be followed when making corrections to errors in the factual reports
And a few gray areas that might allow admissability of portions of the report, or complete review by expert witnesses otherwise involved in a civil proceeding
http://olsonbrooksby.com/blog/tag/admissibility-of-ntsb-fact-reports/
http://www.mondaq.com/unitedstates/x/159518/Marine+Shipping/Using+Accident+Reports+In+Casualty+Litigation
I don't think that contacting the NTSB about this amounts to having an ax to grind. Their report contains two conflicting statements which are both presented as fact. One of them has to be wrong. And if this accident ends up on court, the issue of whether the engineer of #175 did everything possible to prevent or mitigate the accident will be important. One of the NTSB statements indicates the engineer did do everything possible, and the other indicates that she did not.
Furthermore, the issue of how this detail is presented in two conflicting ways in the report is not difficult to explain or to understand.
I suggest writing a letter to them. I have contacted them by phone in the past and the person answering always says they will have some higher authority call me back. But they never do.
In the interests of avoiding hippoerythritic splatter to a greater degree:
Remember the NTSB proceedings are not admissible per se in court, and I believe that includes civil as well as criminal proceedings.
Assuredly Ms. Sahara will be put on the stand at any trial, and the contradiction more or less definitively resolved ... that is, if Amtrak's counsel is better than what CSX used for the Midnight Rider business.
It won't matter if the government agency made stupid mistakes or showed how far off their 'aircraft' standards that report actually was.
In my opinion we should take it as what it is: a mistake, possibly intentional but certainly incorrect, and 'leave it to heaven'. And I say this as a grammar and rhetoric nut who gets irritated every time I think of the situation. Game to get it fixed, or even acknowledged, is not worth the candle; in any case, I doubt even with Bella gone they'd have learned anything about careful correctness instead of furthering perceived or putative agendas, for the next time.
Overmod In the interests of avoiding hippoerythritic splatter to a greater degree: Remember the NTSB proceedings are not admissible per se in court, and I believe that includes civil as well as criminal proceedings. Assuredly Ms. Sahara will be put on the stand at any trial, and the contradiction more or less definitively resolved ... that is, if Amtrak's counsel is better than what CSX used for the Midnight Rider business. It won't matter if the government agency made stupid mistakes or showed how far off their 'aircraft' standards that report actually was. In my opinion we should take it as what it is: a mistake, possibly intentional but certainly incorrect, and 'leave it to heaven'. And I say this as a grammar and rhetoric nut who gets irritated every time I think of the situation. Game to get it fixed, or even acknowledged, is not worth the candle; in any case, I doubt even with Bella gone they'd have learned anything about careful correctness instead of furthering perceived or putative agendas, for the next time.
Euclid I mention court, just to indicate how important the issue is, and how important it is that the NTSB appears not to care about their flawed report, at the same time they take their work so seriously that it takes years to get the report out. That's all I'm saying.
They certainly made a monkey out of me after I praised their impartiality and implicit professionalism. Ah well: the Newcomen Society isn't what it used to be in this country, either.
Overmod Euclid I mention court, just to indicate how important the issue is, and how important it is that the NTSB appears not to care about their flawed report, at the same time they take their work so seriously that it takes years to get the report out. That's all I'm saying. They certainly made a monkey out of me after I praised their impartiality and implicit professionalism. Ah well: the Newcomen Society isn't what it used to be in this country, either.
NTSB's professionalism has been trending toward the political for the past 20 years or more.
Never too old to have a happy childhood!
Besides the blatant controdiction about when the engineer of #175 made the emergency application, that report contains some of the most ambiguous writing I have ever seen. The problems are in their analysis of the factors affecting the two victims, the recommendations, and the probable cause. That portion raises many questions that the NTSB report seems to be unaware of. Also, the way they conduct the interviews; their questions, and the resulting answers create an almost childlike narrative that seems to address what each other are thinking as much as what they actually say. To a reader, much of the interview is incomprehensible.
EuclidAlso, the way they conduct the interviews; their questions, and the resulting answers create an almost childlike narrative that seems to address what each other are thinking as much as what they actually say. To a reader, much of the interview is incomprehensible.
In my opinion, the ambiguity encountered in reports like this is intentional, often mimicking the spurious attempts at 'imprecise precision' found when speaking or writing Military-Industrial.
It's pretty clear that these guys were running the 'we're from the government and we're here to help you' type of fact finding: where they're acting all concerned about potential PTSD and so on, but slipping in their careful little lawyers' questions to see who might trip up whom. It pays to watch for this when evaluating what government inspectors of any 'stripe' do: they are only "your" friends when it suits their agency's, or their agency's friends or superiors, perceived wants. At the time. (But what you say is just as 'applicable' after they change their minds or their tune...)
I had the very strong impression that there were factors other than performance, affecting Amtrak concerns that I'm not prepared to discuss on this forum (as they likely involve either permanent moderation or banning even in context), which may or may not be geared as I think they were in Bostian's case toward letting crew out of 'personal' liability ... or sticking them with blame ... depending on the 'secret woids' they've been told to keep in mind.
In this particular case, it seems pretty clear that Sahara kept from applying the independent until after the actual impact, and then says she only did so because she'd 'have to'. Especially after Midnight Rider that's really going to sit badly with victims' counsel, and likely with any judge or jury. So instead we have a report that tells 'all and sundry' who don't have access to, say, further discovery that she did, in fact, apply the emergency 'right away'... or appears to do so by using confusing language.
I do wish that a supposedly impartial 'finder of fact' agency would avoid using typical Government techniques. But I'm not such a fool as to expect that anymore.
Overmod Euclid Also, the way they conduct the interviews; their questions, and the resulting answers create an almost childlike narrative that seems to address what each other are thinking as much as what they actually say. To a reader, much of the interview is incomprehensible. In my opinion, the ambiguity encountered in reports like this is intentional,... I had the very strong impression that there were factors other than performance, affecting Amtrak concerns that I'm not prepared to discuss on this forum (as they likely involve either permanent moderation or banning even in context), which may or may not be geared as I think they were in Bostian's case toward letting crew out of 'personal' liability ... or sticking them with blame ... depending on the 'secret woids' they've been told to keep in mind. In this particular case, it seems pretty clear that Sahara kept from applying the independent until after the actual impact, and then says she only did so because she'd 'have to'. ...So instead we have a report that tells 'all and sundry' who don't have access to, say, further discovery that she did, in fact, apply the emergency 'right away'... or appears to do so by using confusing language.
Euclid Also, the way they conduct the interviews; their questions, and the resulting answers create an almost childlike narrative that seems to address what each other are thinking as much as what they actually say. To a reader, much of the interview is incomprehensible.
In my opinion, the ambiguity encountered in reports like this is intentional,...
In this particular case, it seems pretty clear that Sahara kept from applying the independent until after the actual impact, and then says she only did so because she'd 'have to'.
...So instead we have a report that tells 'all and sundry' who don't have access to, say, further discovery that she did, in fact, apply the emergency 'right away'... or appears to do so by using confusing language.
I understand, and agree with you 100%. Apparently, this agenda kicks in whenever NTSB investigates an Amtrak accident.
They did use confusing language in much of the report, and especially in the development of probable cause and in their recommendation.
But in this point about when the engineer made the emergency application, the problem is not due to confusing language. The language is quite clear. In one part, it establishes that the engineer made the emergency application immediately upon seeing the two conductors walking on the track.
The report clearly establishes that the engineer first saw the victims when the train was still at least 540 feet from striking them. Depending on the engineer's estimate of time, it may have been as much as 1,500 feet.
Then later in the report, the engineer states that she made the emergency application immediately after striking them.
This is significant because in a situation where a train is "sneaking up" on someone, the closer it gets, the more likely the person will suddenly recongnize cues such as sound and/or ground vibration. And once this happens, it takes very little time for the person to move into the clear.
Euclidwhere a train is "sneaking up" on someone,
I don't believe that a train doing 75 mph can be considered "sneaking up". More like it's "barrelling down" on them.
Electroliner 1935 Euclid where a train is "sneaking up" on someone, I don't believe that a train doing 75 mph can be considered "sneaking up". More like it's "barrelling down" on them.
Euclid where a train is "sneaking up" on someone,
My comment has nothing to do with the train speed. It refers to the fact that the people fouling the train's path have no awareness of the train approaching behind them.
To the victims, the sound was deafening with both trains simultaneously bearing down on them and blowing their horns. Their attention was riveted on the train they were facing. But while the sound was deafening, they were unable to discriminate that it was coming from two trains instead of one.
I agree with the premise of what I believe to be a fact that the two were unable to discern that there were TWO trains approaching them. And I believe that at the point when #175's engineer saw them, it was too late to save them. Unlike the movies, people cannot launch themselves off a ROW in three or four seconds. There is a discrete period of time to: 1 Sense a danger; 2 Comprehend a danger; 3 Determine a needed action; and 4 execute that action. If they had seen #175 as soon as it became in sight, I doubt they could have reacted in time. As it was they were focused on the train they saw on the other track. It matered not whether #175's engineer applied the brake as soon as she saw them or when the train struck them. Their fate was sealed by them being on a active track without protection.
If you have seen the movie SULLY, you may recall that one of the ideas that made his defense was the time it took to determine where to safely land his plane. The "experts" said they had time to return to Laguardia with their simulations but did not include the time required to determine the problem and determine what action to take. After they added the reaction time, it became clear the Huson River was the ONLY choice and the correct choice for Sully's plane.
The two men were in the wrong place. Hopefully, this will be a teachable moment that can be used to prevent future deaths. Does anyone know whether CSX and Amtrak have established rules and/or practices to prevent future events like this?
Electroliner 1935 I agree with the premise of what I believe to be a fact that the two were unable to discern that there were TWO trains approaching them. And I believe that at the point when #175's engineer saw them, it was too late to save them. Unlike the movies, people cannot launch themselves off a ROW in three or four seconds. There is a discrete period of time to: 1 Sense a danger; 2 Comprehend a danger; 3 Determine a needed action; and 4 execute that action. If they had seen #175 as soon as it became in sight, I doubt they could have reacted in time. As it was they were focused on the train they saw on the other track. It matered not whether #175's engineer applied the brake as soon as she saw them or when the train struck them. Their fate was sealed by them being on a active track without protection. If you have seen the movie SULLY, you may recall that one of the ideas that made his defense was the time it took to determine where to safely land his plane. The "experts" said they had time to return to Laguardia with their simulations but did not include the time required to determine the problem and determine what action to take. After they added the reaction time, it became clear the Huson River was the ONLY choice and the correct choice for Sully's plane. The two men were in the wrong place. Hopefully, this will be a teachable moment that can be used to prevent future deaths. Does anyone know whether CSX and Amtrak have established rules and/or practices to prevent future events like this?
I don’t believe their fate was sealed until the point of impact. I see no outcome that I believe had to have occurred. Why would I believe something that is simply unknowable unless I just did not want to imply that the engineer acted improperly? All I believe is that it was not a certainty that they were beyond saving themselves. It happens every day. Their decision to walk on the track did not lock them into the outcome that occurred. They were not prohibited from walking on the track without protection. They were not required to constantly look back as they walked forward.
They only had to move about 3 feet, and would have acted without any hesitation at the slightest inkling of a train behind them; without even turning to look at the train. 1-2 seconds would have been more than enough time. They most certainly would not have needed time to think about what action they would take, time to think where they would jump to, make calculations, consult experts, etc.
The complex decision you describe with Sully landing his plane is far more complex and time consuming than what would have been needed in the case of these two conductors. Their fate was in a precarious position where any little detail may have changed the outcome. Those details were entirely possible, but none happened in time. But most certainly, their fate was never sealed until they were hit. And a very small amount of extra time may have saved them.
EuclidThe complex decision you describe with Sully landing his plane is far more complex and time consuming than what would have been needed in the case of these two conductors. Their fate was in a precarious position where any little detail may have changed the outcome. Those details were entirely possible, but none happened in time. But most certainly, their fate was never sealed until they were hit. And a very small amount of extra time may have saved them.
Once the birds took out the engines - Sully was fully engaged in his situation - mentally and physically as well as having his co-pilot fully engaged in what was taking place.
The CSX employees were never 'engaged' in their situation as it related to train #175 - as they were focused on train #66. Their lack of reaction to #175 was the cause of their demise.
BaltACD Euclid The complex decision you describe with Sully landing his plane is far more complex and time consuming than what would have been needed in the case of these two conductors. Their fate was in a precarious position where any little detail may have changed the outcome. Those details were entirely possible, but none happened in time. But most certainly, their fate was never sealed until they were hit. And a very small amount of extra time may have saved them. Once the birds took out the engines - Sully was fully engaged in his situation - mentally and physically as well as having his co-pilot fully engaged in what was taking place. The CSX employees were never 'engaged' in their situation as it related to train #175 - as they were focused on train #66. Their lack of reaction to #175 was the cause of their demise.
Euclid The complex decision you describe with Sully landing his plane is far more complex and time consuming than what would have been needed in the case of these two conductors. Their fate was in a precarious position where any little detail may have changed the outcome. Those details were entirely possible, but none happened in time. But most certainly, their fate was never sealed until they were hit. And a very small amount of extra time may have saved them.
Since this is sneaking back into a general discussion of the accident, let me remind everyone that the original 'source material' is not in the defectively written report, but in NTSB docket DCA17MR010, which you can access here, for reference.
I see that in the BLET account the issue of where the conductors were has been resolved: they were walking in the gauge, and some time after they saw 66 approaching they moved across to the "tie butts." If you look at the pictures of the train relative to the two Amtrak mains in the pictures, you can quickly see the possibility of sound from 66 reflecting from the freight consist interfering with anything coming from #175 behind.
It is in this primary material, not a cobbled-up excuse of a summary, that any insight about this accident ... or actual material used for prosecution or defense ... would come. The effect on the press and, through them, the general public, which will never see the detail material and may see only a highly colored interpretation of a flawed piece of expository writing, is quite different, and I have to wonder if the 'spin' implied by the error was intended to act there for some purpose.
EuclidI don’t believe their fate was sealed until the point of impact.
Had #175 been there earlier or significatly later you might be correct, but with the sequence as it occured. the only thing that I can conjur up would have been if 175s horn had sounded first and given them enough sound to overcome the noise of #66.
It is possible that had they had something alert them to #175 approach, they might have been able to react but at 75 ft/sec there wasn't IMHO enough reaction time to savethemselves.
BaltACD Sully was fully engaged in his situation - mentally and physically as well as having his co-pilot fully engaged in what was taking place.
I agree. Have you ever played the game where someone holds a dollar bill between your thumb and index finger and says if you catch it when I let go, you can keep it. Most of the time, it will clear your fingers before you can can close them on it. That is a demonstration of reaction time.
Electroliner 1935 Euclid I don’t believe their fate was sealed until the point of impact. Had #175 been there earlier or significatly later you might be correct, but with the sequence as it occured. the only thing that I can conjur up would have been if 175s horn had sounded first and given them enough sound to overcome the noise of #66. It is possible that had they had something alert them to #175 approach, they might have been able to react but at 75 ft/sec there wasn't IMHO enough reaction time to savethemselves. BaltACD Sully was fully engaged in his situation - mentally and physically as well as having his co-pilot fully engaged in what was taking place. I agree. Have you ever played the game where someone holds a dollar bill between your thumb and index finger and says if you catch it when I let go, you can keep it. Most of the time, it will clear your fingers before you can can close them on it. That is a demonstration of reaction time.
Euclid I don’t believe their fate was sealed until the point of impact.
Depending on the horn signal structure and timing, it was possible at any moment for the signal of #66 to cease and open up a space in which the signal from #175 would have been recognized as coming from behind them, and thus alerted them to jump into the clear. It was also possible that one of them would have just spontaneously turned to check behind, which they have have done several times prior to the approach of the two trains.
Your dollar bill example is a demonstration of reaction time, but the potential reaction time available in this accinent was far longer than what is available in the dollar bill trick. I recall that the engineer of #175 said she was the two conductors walking on the track 15-20 seconds prior to striking them.
What sealed the fate of the two victims more than any other factor was the fact of the two opposing trains approaching simulaneosly. What was second in sealing their fate was the two engineers "laying on the horn" during their approach.
People always talk about how trains can be very quiet when approaching, even at high speed. That is true. But that had nothing to do with this very unique event. With this event, the two trains were not quiet at all. Both probably could have been heard easily from a mile away.
EuclidDepending on the horn signal structure and timing, it was possible at any moment for the signal of #66 to cease and open up a space in which the signal from #175 would have been recognized as coming from behind them, and thus alerted them to jump into the clear.
Note that reflection from the CSX train could have the effect of delaying echoes of 66's horn to make them appear to come 'from behind' with about the same timing and perhaps imaging as anything that would have been coming directly from 175. We haven't discussed the effect of Doppler shift on resolving the two-train issue; it applies in many situations, but perhaps not here. It appears the conductors were alert enough to move from the gauge to the tie-ends upon seeing 66... but not all the way out of fouling Amtrak's line.
Perhaps I'm missing something, but I note pointedly that the event-recorder data for the locomotive on 66 was neither provided nor analyzed. There is a very important datum there -- did the engineer lay on the horn continuously, or nearly so? That plus the echoes would mask anything from 175... and is consistent with their behavior to get further from what they thought was the 'active' rail.
Overmod Euclid Depending on the horn signal structure and timing, it was possible at any moment for the signal of #66 to cease and open up a space in which the signal from #175 would have been recognized as coming from behind them, and thus alerted them to jump into the clear. Note that reflection from the CSX train could have the effect of delaying echoes of 66's horn to make them appear to come 'from behind' with about the same timing and perhaps imaging as anything that would have been coming directly from 175. We haven't discussed the effect of Doppler shift on resolving the two-train issue; it applies in many situations, but perhaps not here. It appears the conductors were alert enough to move from the gauge to the tie-ends upon seeing 66... but not all the way out of fouling Amtrak's line. Perhaps I'm missing something, but I note pointedly that the event-recorder data for the locomotive on 66 was neither provided nor analyzed. There is a very important datum there -- did the engineer lay on the horn continuously, or nearly so? That plus the echoes would mask anything from 175... and is consistent with their behavior to get further from what they thought was the 'active' rail.
Euclid Depending on the horn signal structure and timing, it was possible at any moment for the signal of #66 to cease and open up a space in which the signal from #175 would have been recognized as coming from behind them, and thus alerted them to jump into the clear.
A shoddy investigation would be an understatement.
Your comments on the current discussion about the horns would be helpful.
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